2019 Emergency Shelter Application - New York State Office ...
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2019 Application
for
Homeless Housing and Assistance Program (HHAP)
Existing Emergency Shelter Repairs
Applications Accepted Beginning July 10, 2019
Note on the Completeness of the Application
All proposals received must be in the form and contain the content as set out in this Application. Applications which are deemed incomplete or otherwise fail to meet the requirements of the RFP may be disqualified from consideration.
CHECKLIST
| | | |Check if |
|Exhibit |Check if |Page |Not |
| |Provided |Number(s) |Applicable |
|A-1 |Project Summary Information | | | |
|A-2 |Applicant Information | | | |
|A-3 |Co-Applicant/Supporting Organization Information | | | |
|A-4 |Building Information | | | |
|A-5 |Project Summary Narrative | | | |
|A-6 |Development and Management Team | | | |
|A-7 |Site Control | | | |
| |Evidence of Site Control | | | |
|A-8 |Local Social Services District Approval | | | |
| |Evidence of Local Social Services District Notification | | | |
|B-1 |Development Budget Summary | | | |
|B-2 |Explanation of Development Budget Items | | | |
|B-3 |Description of Non-HHAP Funds Required for Development | | | |
| |Evidence of Commitment of Non-HHAP Funds | | | |
|B-4 |Current Shelter Operating Contract | | | |
|C-1 |OTDA Division of Shelter Oversight and Compliance Operational Plan | | | |
| | | | | |
| |Project Licensing/ Certification (if applicable) | | | |
|C-2 | | | | |
| |Applicant Information and Financial Status | | | |
|D-1 | | | | |
| |Description of Applicant Agency | | | |
| |Board of Directors Profile/Narrative of Relevant Experience | | | |
| |Certificate of Good Standing (long form) | | | |
| |Certificate of Incorporation and all Amendments | | | |
| |By-Laws and all Amendments | | | |
| |IRS 501(c)(3) Ruling (HDFC’s are NFP, but not 501c3) | | | |
| |Sectarian Organization Compliance Checklist | | | |
| |Current Audited Financial Statement (less than one-year old) | | | |
| |Most Recent Uniform Guidance Audit for Federally funded programs (less than one-year| | | |
| |old) | | | |
| |Management Letter (if applicable) | | | |
| |Narrative Explanation of Financial Position | | | |
|D-2 |M/WBE and EEO Participation Requirements and Service-Disabled Veteran-Owned | | | |
| |Businesses (SDVOB) Requirements | | | |
| |M/WBE Equal Employment Opportunity Policy Statement | | | |
| |Staffing Plan | | | |
| |M/WBE Subcontractor Utilization Plan | | | |
| |M/WBE Certification of Good Faith Efforts | | | |
| |Use of Service-Disabled Veteran-Owned Business Enterprises | | | |
| |SDVOB Utilization Plan | | | |
| |SDVOB Application for Waiver of SDVOB Participation Goals | | | |
| D-3 |Contractor/Subcontractor Background Questionnaire | | | |
| |Non-Discrimination in Employment in Northern Ireland | | | |
| |Non-Collusive Bidding Certification | | | |
| |Agreement | | | |
| |Vendor Assurance of No Conflict of Interest or Detrimental Effect | | | |
|E-1 |Site Description | | | |
|E-2 |Scope of Work and Cost Estimate | | | |
|E-3 |Zoning Analysis and Status of Local Approvals | | | |
|E-4 |Project Timeline | | | |
|E-5 |SHPO/SEQRA | | | |
| |Short Environmental Assessment Form | | | |
|E-6 |Flood Plain Letter | | | |
|E-7 |Site Photographs | | | |
|E-8 |Existing Floor Plans | | | |
| |Proposed Floor Plans* | | | |
| | | | | |
EXHIBIT A-1: Project Summary Information
Applicant:
County: (for the proposed project site)
Total Project Units: Total HHAP Units:
Total Project Beds*: Total HHAP Beds*:
Is this an existing Operating HHAP Project: Yes No
Is this a Scattered Site Project: Yes No
Number of Buildings: Gross Square Footage:
Date of Last Inspection: by OTDA: by Local District: by Other:
*Please include a copy of the inspection or investigative report identifying health and safety concerns.
|Development Budget Summary |
|Source |Amount |
|1. HHAP Funds Requested |$ |
|2. |$ |
|3. |$ |
|4. |$ |
|5. |$ |
|6. | $ |
|Total Funds From All Sources |$0[pic]0.00 |
EXHIBIT A-2: Applicant Information
|Incorporated Name: |
|Contact Name: Mr. Ms. Executive Director: Mr. Ms. |
|Title: Title: |
|E-Mail: E-Mail: |
|Mailing Address: |
| |
| |
|County: |
|Phone: | | |
|Legal Status: | Non-Profit | Municipality | Public Corporation |
| | Partnership | Local District | Other: |
|Charities Registration Number: |
|Federal Tax ID#: |Federal Tax-Exempt Status Received? |
|Type (Check all that apply) | |
| City/ Town/ Village Government | Native American Tribal Organization |
| County Government | Public Benefit Corporation |
| Public Housing Authority | Non-Profit Corporation |
| Housing Development Fund Corporation | |
| Jointly-Owned Entity (describe, and identify the involved not-for profit): | |
| | |
|Legislative/Congressional Districts (for Applicant’s offices) |
|NYS Assembly District #: |Representative: |
|NYS Senate District #: |Representative: |
|Congressional District #: |Representative: |
|President, Board of Directors: Mr. Ms. |
|Mailing Address: |
| |
| |
|Phone: |E-Mail: | |
EXHIBIT A-3: Co-Applicant/
Supporting Organization Information
Applicant Type: Co-Applicant Supporting Organization
|Incorporated Name: |
|Contact Name: Mr. Ms. |
|Title: |
|Mailing Address: |
| |
| |
|County: |
|Phone: | |E-Mail: |
|Legal Status: | Non-Profit | Municipality | Public Corporation |
| | Partnership | Local District | Other |
|Charities Registration Number: |
|Federal Tax ID#: |Federal Tax-Exempt Status Received? |
|Type (Check all that apply) | |
| City/ Town/ Village Government | Native American Tribal Organization |
| County Government | Public Benefit Corporation |
| Public Housing Authority | Non-Profit Corporation |
| Housing Development Fund Corporation | |
| Jointly-Owned Entity (describe, and identify the involved not-for profit): | |
|Legislative/Congressional Districts (for Co-Applicant’s offices) |
|NYS Assembly District #: |Representative: |
|NYS Senate District #: |Representative: |
|Congressional District #: |Representative: |
|President, Board of Directors: Mr. Ms. |
|Mailing Address: |
| |
| |
|Phone: |E-Mail: | |
EXHIBIT A-4: Building Information (Page 1 of 2)
Project Building Number: of
Note: This section is used by HHAP to collect basic information about each building. This section should be completed AFTER the rest of the application has been prepared. If more than one building is proposed for the project, duplicate and complete this page for each site (building) in the proposal and provide a summary page presenting cumulative information for all sites.
Total Building Units: HHAP Units:
Building Units and Beds
Total Emergency Units: HHAP Emergency Units:
Total Building Beds: HHAP Beds:
Total Emergency Beds: HHAP Emergency Beds:
Unit Breakdown
Congregate Units: Total Units HHAP Units
Special Populations (e.g., family shelter vs. singles, male vs. female, etc.)
____________________ Total Units HHAP Units
____________________ Total Units HHAP Units
____________________ Total Units HHAP Units
|Legislative/Congressional Districts (for proposed project site) |
|NYS Assembly District #: |Representative: |
|NYS Senate District #: |Representative: |
|Congressional District #: |Representative: |
EXHIBIT A-4: Building Information (Page 2 of 2)
Project Building Number: of
Note: This section is used by HHAP to collect basic information about each building. This section should be completed AFTER the rest of the application has been completed. If more than one building is proposed for the project, duplicate and complete this page for each site (building) in the proposal.
Street:
Number Name
Municipality:
Zip:
Municipality Type: City County Town Village
County:
Parcel Section #: Block #: Lot #:
Easement #: Census Tract #:
Current Owner:
Building Gross Square Footage:
Activity Proposed (Check all that apply):
Moderate Rehabilitation
Purchase Equipment
Can this site be developed “as of right”? Yes No
If No, identify contingencies:
Code Variance Special Use Permit Use Variance Other:
Area Variance Easement Site Plan Review
EXHIBIT A-5: Project Summary Narrative
Provide a complete narrative summary of the proposal. The narrative should be presented in such a way so that someone who has not read the application will have a clear understanding of the proposed project. At a minimum, please include the following: sponsor; co-sponsor; HHAP request; total funding necessary to complete the project; sources and status of other funding; total number of units and beds location; type of repairs needed; and source of operating funds.
Provide a detailed narrative explaining how the proposed project will promote the health, safety, and well-being of the residents. Explain any support services that will improve the health of residents, specifically: prevent chronic disease; promote a healthy and safe environment; promote the health of women, infants and children; promote well-being and prevent mental health and substance use disorders; and/or prevent communicable diseases
Add additional sheets if needed and label Project Summary
EXHIBIT A-6: Development and Management Team (Page 1 of 2)
Provide contact information for all members of the proposed development and management team. Add additional sheets as necessary.
|Consultant: |
|Firm: |
|Contact: Mr. Ms. |
|Mailing Address: |
| |
|Phone: | |E-Mail: |
|Architect: |
|Firm: |
|Contact: Mr. Ms. |
|Mailing Address: |
| |
|Phone: | |E-Mail: |
|Attorney: |
|Firm: |
|Contact: Mr. Ms. |
|Mailing Address: |
| |
|Phone: | |E-Mail: |
|Other (specify): |
|Firm: |
|Contact: Mr. Ms. |
|Mailing Address: |
| |
|Phone: | |E-Mail: |
|Other (specify): |
|Firm: |
|Contact: Mr. Ms. |
|Mailing Address: |
| |
|Phone: | |E-Mail: |
EXHIBIT A-6: Development and Management Team
(Page 2 of 2)
A) Detail the respective roles and responsibilities of each entity necessary for the development, operation and provision of services at the proposed project. Please include a brief synopsis of the relevant experience of each entity, and identify any prior experience with HHAP, if applicable.
B) Identify below whether there is any direct or indirect financial or other interest that any member of the development or management team may have with any other member of the team (including the applicant or co-applicant) or the funding of this project. See Section III. A. 2 of the RFP for definition of “development team.”
C) Please refer to Appendix H of the Request for Proposals and identify below whether any potential conflict of interest exists.
D) Following this page, please briefly describe the qualifications of the proposed consultant and include a draft scope of work, if applicable.
EXHIBIT A-7: Site Control
(Prepare a separate page for each building/site)
Site of
Site Address:
Street City Zip
Who currently owns this site?
Describe the relationship (if any) between the current owner and applicant (including board members, officers, staff, and/or their family members).
If the applicant currently owns the site, explain when it was acquired, the price and any special conditions under which it was acquired, and the uses of the site, if any, since acquired.
If the applicant currently owns the site, explain any deed restrictions affecting the project site.
Check below the level of site control documentation available, and attach such documentation following this page (check all that apply).
For sites currently owned/leased:
Deed
Lease
Letter from Public Agency
Other (specify):
EXHIBIT A-8: Local Social Services District Approval/ Community Relations
Following this page, please attach the items requested below:
Documentation that the Local Social Services District has been notified of the funding request for the project.
If applicable, a statement from the local Continuum of Care supporting the proposed project.
|EXHIBIT B-1: Development Budget Summary |
|(Following this page detail Legal, Consultant, Furniture, Equipment and Start-Up Costs) |
|Address: |
| | |HHAP |Other Source 1 |Other Source 2 |TOTAL |
|A. |ACQUISITION | | | | |
| |1. Cost of Building/Land |$0 |$0 |$0 |$$0.00[pic]0 |
|B. |ACQUISITION-RELATED COSTS | | | | |
| |1. Appraisal |$0 |$0 |$0 |$$0.00[pic]0 |
| |2. Closing Fees |$0 |$0 |$0 |$$0.00[pic]0 |
| |3. Title Insurance |$0 |$0 |$0 |$$0.00[pic]0 |
| |4. Legal Fees (Related to Acquisition) |$0 |$0 |$0 |$$0.00[pic]0 |
| |5. Other (e.g. buy-down of existing mortgage) |$0 |$0 |$0 |$$0.00[pic]0 |
| |6. TOTAL LINES 1 -5 |$$0.00[pic]0 |$$0.00[pic]0 |$$0.00[pic]0 |$$0.00[pic]0 |
|C. |CONSTRUCTION COSTS | | | | |
| |1. Construction/Rehabilitation |$0 |$0 |$0 |$$0.00[pic]0 |
| |2. Contingency (5% new; 10% rehab) |$0 |$0 |$0 |$$0.00[pic]0 |
| |3. Construction Manager Fee ( %) |$0 |$0 |$0 |$$0.00[pic]0 |
| |4. TOTAL LINES 1 - 3 |$$0.00[pic]0 |$$0.00[pic]0 |$$0.00[pic]0 |$$0.00[pic]0 |
|D. |PROFESSIONAL SERVICE FEES | | | | |
| |1. Architectural |$0 |$0 |$0 |$$0.00[pic]0 |
| |2. Legal Fees (Unrelated to Acquisition) |$0 |$0 |$0 |$$0.00[pic]0 |
| |3. Consultant* |$0 |$0 |$0 |$$0.00[pic]0 |
| |4. Developer's Fee* |$0 |$0 |$0 |$$0.00[pic]0 |
| |5. Other (define) |$0 |$0 |$0 |$$0.00[pic]0 |
| |6. TOTAL LINES 1 - 5 |$$0.00[pic]0 |$$0.00[pic]0 |$$0.00[pic]0 |$$0.00[pic]0 |
|E. |OTHER DEVELOPMENT COSTS | | | | |
| |1. Survey |$0 |$0 |$0 |$$0.00[pic]0 |
| |2. Asbestos Test, Abatement, Monitoring |$0 |$0 |$0 |$$0.00[pic]0 |
| |3. Owners Insurance for Construction |$0 |$0 |$0 |$$0.00[pic]0 |
| |4. Tax Exemption Fees |$0 |$0 |$0 |$$0.00[pic]0 |
| |5. Lead Test, Abatement, Monitoring |$0 |$0 |$0 |$$0.00[pic]0 |
| |6. Other (define) |$0 |$0 |$0 |$$0.00[pic]0 |
| |7. TOTAL LINES 1 - 6 |$$0.00[pic]0 |$$0.00[pic]0 |$$0.00[pic]0 |$$0.00[pic]0 |
|F. |TOTAL DEVELOPMENT COST (B - E) |$$0.00[pic]0 |$$0.00[pic]0 |$$0.00[pic]0 |$$0.00[pic]0 |
|G. |OTHER THAN PROJECT COSTS | | | | |
| |1. Furniture and Equipment |$0 |$0 |$0 |$$0.00[pic]0 |
| |2. Start-up Costs |$0 |$0 |$0 |$$0.00[pic]0 |
| |3. Replacement Reserve |$0 |$0 |$0 |$$0.00[pic]0 |
| |4. Operating Reserve |$0 |$0 |$0 |$$0.00[pic]0 |
| |5. TOTAL LINES 1 -4 |$$0.00[pic]0 |$$0.00[pic]0 |$$0.00[pic]0 |$$0.00[pic]0 |
|H. |TOTAL PROJECT COST (A+F+G) |$$0.00[pic]0 |$$0.00[pic]0 |$$0.00[pic]0 |$$0.00[pic]0 |
*Refer to Maximum limits allowed by RFP
If more than one site, whether identified or not, this form MUST be completed for each site and a cumulative budget representing all sites must be presented. The Development Budget should reflect construction financing. Permanent sources and uses are described in Exhibit B-3.
EXHIBIT B-2: Explanation of Development Budget Items
Please describe the basis for determining the cost of all items in the development budget. Specifically include how the amounts requested were determined for the following items, if applicable: repair or replacement of a roof; repairs or replacement of heating and/or cooling system; electrical and/or plumbing work necessary to address safety concerns; structural work; installation of appropriate fire and smoke detectors; improved safety features such as metal detectors and/or cameras in common areas; hazardous materials testing, abatement, and monitoring; and equipment. If the costs are based on quotes, please attach documentation of the quotes following this page. If costs are based on agency experience with a similar project, identify and describe that project. Please provide the information for all line items, not just those to be funded by HHAP.
EXHIBIT B-3: Description of Non-HHAP Funds
Required for Development
Please summarize below the status of commitment as well as the terms and conditions (i.e., interest rate, restrictions, timeline for availability, length of loan, etc.) of:
1) Any mortgages currently held on the project site (if the applicant already owns the property and/or will assume or buy down any existing mortgages).
2) Any loans or major grants required for project development that have been applied for or already have committed to the project.
3) Any private investment/partnership involved in project financing. If a partnership will be involved, include information, if available, on the identity and background of the general partner and actual or potential investors, structure of the syndication, and other relevant details of the proposed partnership.
4) Attach copies of all letters of commitment/interest from other funding sources.
5) Do any of the funding sources involved in the project trigger prevailing wage requirements?
No
Yes
EXHIBIT B-4: Shelter Operating Contract Budget
Please submit your current Shelter Operating budget included in your contract with the Local Social Services District.
Sample:
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EXHIBIT C-1: OTDA Division of Shelter Oversight and Compliance
1) Has your Operational Plan been submitted to the Local Social Services District?
Yes No Date:
If not submitted, please explain:
2) Has your Operational Plan been submitted to the OTDA Division of Shelter Oversight and Compliance?
Yes No Date:
If not submitted, please explain:
EXHIBIT C-2: Project Licensing/ Certification
1) If the proposed project requires certification, please provide a copy. If the shelter is not currently certified, please explain.
2) If currently certified, please provide the following:
Certifying Agency and Division:
Type of Certificate Required:
Contact Person at Certifying Agency:
Telephone Number:
3) Please provide a narrative describing any certifying agency’s approval process for the facility to resume operations upon completion of proposed work.
Note: HHAC will not consider funding licensed, certified or otherwise regulated programs without sufficient revenue or a preliminary commitment for funds sufficient to complete the proposed scope of work.
EXHIBT D-1:
Applicant Information and Financial Status
Agency Narrative: Provide a description of the applicant organization, and if applicable, any co-sponsor or supporting organization, including the year it was founded, its mission, and major accomplishments. Describe the applicant agency’s experience in shelter operations, management, and human services, as well as the age of the shelter proposed for repairs, the agency’s difficulty in securing alternative funding for the repairs, and the agency’s experience servicing the community. Provide other information that demonstrates the applicant’s capacity to carry out the proposed project such as information regarding the applicant’s experience with special needs populations proposed for the project.
In addition to each narrative, for each entity involved in the project (applicant, co-applicant, and supporting organization), please refer to the matrix on the next page and attach the required information, as applicable, unless available through the Grants Gateway Document Vault. Shaded areas indicate that the item is not available through the Grants Gateway Document Vault and must be included with the application. Please note that although current financial statements are among the items available in the Document Vault, HHAC requires that a copy of the organization’s current financial statements, as well as the financial statements from the previous fiscal year, be included with the application, including the Single Audit (U.S. Office of Management and Budget OMB circular Uniform Guidance Audit), if required.
As a reminder, HHAP is restricted to only contracting with non-profit entities or their wholly-owned subsidiaries, municipalities, public corporations, charitable organizations or their wholly-owned subsidiaries, or qualifying jointly-owned entities. Any proposed contracting entity structure that is essentially for-profit in nature or that cannot be characterized as having a non-profit with majority interest and control cannot be considered for funding under this RFP.
|Agency Information Matrix |
| |
|For each corporate entity involved in the project (applicant, co-applicant, and supporting organization), please submit the following documents, as |
|applicable: |
|Required Information |Include with Application |Included in Grants Gateway Document Vault |
|General Information | | |
|M/WBE and EEO Policy Statement |(form provided) | |
|Corporate Documents | | |
|(Supporting Organizations Exempt) | | |
|Board of Directors Profile and a narrative description of the | |Yes |
|relevant experience of Board Members | |Please make sure this is an up-to-date Board|
| | |Profile |
|Certificate of Good Standing (long form) * |Yes | |
|Certificate of Incorporation and any and all amendments thereto, | |Yes |
|along with filing receipts with the New York State Department of | |Please make sure this includes all |
|State with respect to each document. | |amendments |
|By-Laws, including any and all amendments thereto | |Yes |
|IRS 501(c)(3) Ruling | |Yes |
|Faith-Based (Sectarian) Organization Compliance Checklist ** |(form provided) | |
|A complete set of current (less than one year old) audited |Yes |Yes |
|financial statements prepared by an independent certified public | | |
|accountant for the applicant agency and any supporting organization| | |
|or co-applicant ***. Financial statements for the two most recent | | |
|fiscal years available are required. | | |
|Singe Audit (Uniform Guidance Audit), if required. |Yes |Yes |
| |
*A Certificate of Good Standing can be obtained from the NYS Department of State (dos.state.ny.us). Please allow sufficient time to order the Certificate to ensure that it is included in the application and make sure to order the long form, rather than the short form, which lists only name change amendments.
**The NYS Attorney General’s Office has determined that any organization whose incorporated name carries a sectarian moniker must list itself as a sectarian organization. This includes all YWCA/YMCA’s, Catholic Charities, and organizations that carry the names of saints, biblical figures, etc. Designation as a sectarian organization will not adversely affect the proposal as long as the form indicates that the applicant will not discriminate in providing services.
***It is HHAC’s responsibility to determine whether in its opinion applicants appear financially stable, not only currently, but also over the life of the project. As such, we will closely scrutinize the financial information provided and evaluate whether applicants possess the organizational infrastructure necessary to both develop the HHAP project and successfully maintain it for the contractually-mandated period of time. The financial statements should present a classified balance sheet identifying current assets and current liabilities, as required by Generally Accepted Accounting Principles (GAAP). Any management letters issued should also be provided.
To complete the financial review, HHAC must understand the financial impact of affiliated organizations on the applicant. Therefore, please provide:
- a list of affiliates, their purpose, any significant contingencies and the relationship of the affiliate to the applicant; and
- the consolidated audit and the separate audited financial statements of any significant affiliate if not included in the consolidated audit statements provided above.
Note: Please remember that the audited financial statement must stand on its own. Do not assume that the reviewers know anything about the applicant organization. Therefore, if the applicant’s financial statements are more than one-year old or contain information that may reasonably imply that the applicant organization is or may be experiencing financial difficulties (i.e., negative working capital, maximized line(s) of credit, audit findings, pending lawsuits, etc.), a narrative explanation of fiscal standing must be included.
Faith-Based (Sectarian) Organization Compliance Checklist
YES NO
1) Is the applicant agency a faith-based (sectarian) organization? (For example,
a corporation organized under the religious corporation law or a corporation
which has as a corporate purpose the provision of services to a particular religious
group or promoting the doctrine of a particular religion or religion in general.)
2) Are any of the services proposed in this application sectarian in nature?
3) Does the applicant have as its goal the furthering of any sectarian purpose?
4) Are services to be provided by sectarian staff (clergy)?
5) Are services being delivered in a building owned by a faith-based organization?
6) Will the proposed services be provided on the basis of race, religion, color or
national origin?
If any of the above answers if yes, below please provide specific information relating to the response.
EXHIBIT D-2:
M/WBE and Equal Employment Opportunity
Participation Requirements and Service-Disabled Veteran-Owned Businesses (SDVOB)
M/WBE-Equal Employment Opportunity Policy Statement (OTDA-4970) *
Staffing Plan (OTDA-4934) *
M/WBE Subcontractor Utilization Plan (OTDA-4937) *
M/WBE Goal Requirement Certification of Good Faith Efforts (OTDA-4976)
SDVOB Utilization Plan (SDVOB-100)
SDVOB Application for Waiver of SDVOB Participation Goals (SDVOB-200)
Please complete all forms according to the instructions. Required forms are included below. The Letter of Intent to Participate and Request for Waiver forms are not included in the application. If necessary and applicable to the application, these forms are located on OTDA’s website at:
Note: An M/WBE or SDVOB Waiver Form may only be submitted and considered in circumstances where good faith efforts can be documented as detailed more fully in the instructions of the Waiver Form.
Note: The submission of M/WBE Quarterly Reports will be required throughout the development of the project, as HHAP funds are expended.
OTDA – 4970 (Rev. 11/16)
MINORITY AND WOMEN-OWNED BUSINESS ENTERPRISES- EQUAL EMPLOYMENT OPPORTUNITY
POLICY STATEMENT
M/WBE AND EEO POLICY STATEMENT
I, , the (awardee/contractor) agree to adopt the following policies with respect to the project being developed or services rendered at
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This organization will and will cause its contractors and subcontractors to take good faith actions to achieve the M/WBE contract participations goals set by the State for that area in which the State-funded project is located, by taking the following steps:
1) Actively and affirmatively solicit bids for contracts and subcontracts from qualified State certified MBEs or WBEs, including solicitations to M/WBE contractor associations.
2) Request a list of State-certified M/WBEs from AGENCY and solicit bids from them directly.
3) Ensure that plans, specifications, request for proposals and other documents used to secure bids will be made available in sufficient time for review by prospective M/WBEs.
4) Where feasible, divide the work into smaller portions to enhanced participations by M/WBEs and encourage the formation of joint venture and other partnerships among M/WBE contractors to enhance their participation.
5) Document and maintain records of bid solicitation, including those to M/WBEs and the results thereof. The Contractor will also maintain records of actions that its subcontractors have taken toward meeting M/WBE contract participation goals.
6) Ensure that progress payments to M/WBEs are made on a timely basis so that undue financial hardship is avoided, and that, if legally permissible, bonding and other credit requirements are waived or appropriate alternatives developed to encourage M/WBE participation.
a) This organization will not discriminate against any employee or applicant for employment because of race, creed, color, national origin, sex, age, disability or marital status, will undertake or continue existing programs of affirmative action to ensure that minority group members are afforded equal employment opportunities without discrimination, and shall make and document its conscientious and active efforts to employ and utilize minority group members and women in its work force on state contracts.
b) This organization shall state in all solicitation or advertisements for employees that in the performance of the State contract all qualified applicants will be afforded equal employment opportunities without discrimination because of race, creed, color, national origin, sex disability or marital status.
c) At the request of the contracting agency, this organization shall request each employment agency, labor union, or authorized representative will not discriminate on the basis of race, creed, color, national origin, sex, age, disability or marital status and that such union or representative will affirmatively cooperate in the implementation of this organization’s obligations herein.
d) The Contractor shall comply with the provisions of the Human Rights Law, all other State and Federal statutory and constitutional non-discrimination provisions. The Contractor and subcontractors shall not discriminate against any employee or applicant for employment because of race, creed (religion), color, sex, national origin, sexual orientation, military status, age, disability, predisposing genetic characteristic, marital status or domestic violence victim status, and shall also follow the requirements of the Human Rights Law with regard to non- discrimination on the basis of prior criminal conviction and prior arrest.
e) This organization will include the provisions of sections (a) through (d) of this agreement in every subcontract in such a manner that the requirements of the subdivisions will be binding upon each subcontractor as to work in connection with the State contract
Agreed to this day of , 2
By
Print: Title:
is designated as the Minority Business Enterprise Liaison (Name of Designated Liaison)
responsible for administering the Minority and Women-Owned Business Enterprises- Equal Employment Opportunity (M/WBE-EEO) program.
M/WBE Contract Goals
% Minority and Women’s Business Enterprise Participation
% Minority Business Enterprise Participation
% Women’s Business Enterprise Participation
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(Authorized Representative)
Title:
Date:
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OTDA – 4937 (Rev. 1/2016)
M/WBE UTILIZATION PLAN
INSTRUCTIONS: This form must be submitted with any bid, proposal, or proposed negotiated contract or within a reasonable time thereafter, but prior to contract award. This Utilization Plan must contain a detailed description of the supplies and/or services to be provided by each certified Minority and Women-owned Business Enterprise (M/WBE) under the contract. Note – A dually certified firm cannot be counted toward both the MBE and WBE participation goals. Attach additional sheets if necessary.
Offeror’s Name: Federal Identification No.:
Address: Solicitation Name/Contract No.:
City, State, Zip Code: MWBE Certified: Y/N
Telephone No.: M/WBE Participation Goals: MBE % WBE %
Region/Location of Work:
| | | | | |
|1. Certified M/WBE Subcontractors/Suppliers |2. Classification |3. Federal ID No. |4. Detailed Description of Work |5. Dollar Value of Subcontracts/ |
|Name, Address, Email Address, Telephone No. | | |(Attach additional sheets, if necessary) |Supplies/Services and intended performance|
| | | | |dates of each component of the contract. |
|A. |NYS ESD CERTIFIED | | | |
| |MBE | | | |
| |WBE | | | |
|B. |NYS ESD CERTIFIED | | | |
| |MBE | | | |
| |WBE | | | |
|6. IF UNABLE TO FULLY MEET THE MBE AND WBE GOALS SET FORTH IN THE CONTRACT, OFFEROR MUST SUBMIT A REQUEST FOR WAIVER FORM - OTDA - 4969. |
|PREPARED BY (Signature): |TELEPHONE NO.: | |
|DATE: | |EMAIL ADDRESS: |
| | | |
|NAME AND TITLE OF PREPARER (Print or Type): | | |
| | | |
| | | |
|SUBMISSION OF THIS FORM CONSTITUTES THE OFFEROR’S ACKNOWLEDGEMENT AND AGREEMENT TO COMPLY WITH THE M/WBE REQUIREMENTS SET | | |
|FORTH UNDER NYS EXECUTIVE LAW, ARTICLE 15-A, 5 NYCRR PART 143, AND THE ABOVE-REFERENCED SOLICITATION. FAILUR TO SUBMIT | | |
|COMPLETE AND ACCURATE INFORMATION MAY RESULT IN A FINDING OF NONCOMPLIANCE AND POSSIBLE TERMINATION OF YOUR CONTRACT. | | |
| |FOR M/WBE USE ONLY |
| |REVIEWED BY: |DATE: |
| | | |
| | |
| |UTILIZATION PLAN APPROVED: YES NO Date: |
| |Contract No.: |
| | |
| |Contract Award Date: |
| |Estimated Date of Completion: |
| |Amount Obligated Under the Contract: |
| |Description of Work: |
| | |
| |NOTICE OF DEFICIENCY ISSUED: YES NO Date:______________ |
| | |
| |NOTICE OF ACCEPTANCE ISSUED: YES NO Date:_____________ |
OTDA-4976 (Rev. 1/2016)
M/WBE GOAL REQUIREMENTS
CERTIFICATION OF GOOD FAITH EFFORTS
Contractors (to include those who submit bids/proposals in an effort to be selected for contract award as well as those successful bidders/proposers with whom OTDA enters into State contracts) must document “good faith efforts” to provide meaningful participation by New York State Certified M/WBE subcontractors or suppliers/vendors in the performance of this contract.
The undersigned hereby acknowledges that he/she took or may need to take the following actions on behalf of the Contractor to demonstrate, and upon request by OTDA, to provide written verification to document the aforesaid good faith efforts:
a) The Contractor attended any pre-bid, pre-award, or other meetings scheduled by the contracting agency or the NYS Department of Economic Development or its designee to inform certified minority- or women-owned business enterprises of contracting and subcontracting opportunities available on the project, for purposes of complying with contract participation goal requirements;
b) The Contractor identified economically feasible units of the project that could be contracted or subcontracted to certified minority- and women-owned business enterprises in order to increase the likelihood of participation by such enterprises on the contract;
c) The Contractor undertook efforts to reasonably structure the contract scope of work for purposes of subcontracting with certified minority- and- women-owned business enterprises;
d) The Contractor advertised in a timely fashion and in appropriate general circulation, trade and minority- and women-oriented publications, if any, concerning the contracting or subcontracting opportunity;
e) The Contractor made written solicitations in a timely fashion to a reasonable number of certified minority- and women- owned business enterprises identified from current certified lists of such business enterprises provided or maintained by the NYS Empire State Development’s Division of Minority and Women Owned Business Development, or its designee, of the contracting or subcontracting opportunity. The directory of certified businesses can be viewed at:
f) The Contractor can document if any timely responses to any such advertisements and solicitations were provided by certified minority- and women-owned business enterprises;
g) The Contractor followed-up initial solicitations by contacting the enterprises to determine whether the enterprises were interested in such contracting or subcontracting opportunity;
h) The Contractor provided interested certified minority- and women-owned business enterprises in a timely fashion with adequate information about the plans, specifications or terms and conditions of the State contract and requirements for the contracting or subcontracting opportunity so as to prepare an informed response to a contractor solicitation;
i) The Contractor submitted a completed, acceptable utilization plan in accordance with applicable requirements to meet goals for participation of certified minority-and women-owned business enterprises established in the State contract;
j) The Contractor used the services of community organizations, contractor groups, state and federal business assistance offices and other organizations identified by the NYS Department of Economic Development or its designee that provide assistance in the recruitment and placement of minority and women business enterprises;
(k) The Contractor negotiated in good faith with certified minority- and women-owned business enterprises submitting bids, proposals, or quotations and did not, without justifiable reason, reject as unsatisfactory any bids, proposals or quotations prepared by any certified minority- or women-owned business enterprise. "Good faith" negotiating means engaging in good faith discussions with certified minority- or women-owned business enterprises about the nature of the work, scheduling, requirements for special equipment, opportunities for dividing of work among the bidders, proposers, and various subcontractors and the bids of the minority or women businesses, including sharing with them any cost estimates from the request for proposal or invitation to bid documents, if available; and,
(l) The Contractor undertook efforts to make payments for any work performed by certified minority- and women-owned business enterprises in a timely fashion so as to facilitate continued performance by certified minority- and women-owned business enterprises.
_______________________________________
Signature Date
_______________________________________
Print Name
_______________________________________
Title
_______________________________________
Company
_______________________________________
Contract Number
______________________________________
Program/Solicitation Name
USE OF SERVICE-DISABLED VETERAN-OWNED BUSINESS ENTERPRISES
Article 17-B of the Executive Law enacted in 2014 acknowledges that Service-Disabled Veteran-Owned Businesses (SDVOBs) strongly contribute to the economies of the State and the nation. As defenders of our nation and in recognition of their economic activity in doing business in New York State, bidders/proposers for this contract for commodities, services or technology are strongly encouraged and expected to consider SDVOBs in the fulfillment of the requirements of the contract. Such partnering may be as subcontractors, suppliers, protégés or other supporting roles. SDVOBs can be readily identified on the directory of certified businesses at .
Bidders/ proposers need to be aware that all authorized users of this contract will be strongly encouraged to the maximum extent practical and consistent with legal requirements of the State Finance Law and the Executive Law to use responsible and responsive SDVOBs in purchasing and utilizing commodities, services and technology that are of equal quality and functionality to those that may be obtained from non-SDVOBs. Furthermore, bidders/proposers are reminded that they must continue to utilize small, minority and women-owned businesses consistent with current State law.
Utilizing SDVOBs in State contracts will help create more private sector jobs, rebuild New York State’s infrastructure, and maximize economic activity to the mutual benefit of the contractor and its SDVOB partners. SDVOBs will promote the contractor’s optimal performance under the contract, thereby fully benefiting the public-sector programs that are supported by associated public procurements.
Public procurements can drive and improve the State’s economic engine through promotion of the use of SDVOBs by its contractors. The State, therefore, expects bidders/proposers to provide maximum assistance to SDVOBs in their contract performance. The potential participation by all kinds of SDVOBs will deliver great value to the State and its taxpayers.
Bidders/ proposers will complete and submit a Service-Disabled Veteran-Owned Business (SDVOB) Utilization Plan (SDVOB-100), to demonstrate their proposed utilization of NYS certified SDVOBs as part of their bid/proposal. However, if after making a good faith effort to achieve the SDVOB participation goal, applicants are unable to achieve the SDVOB participation goal, they may submit an Application for Waiver of SDVOB Participation Goal.
For more detailed information regarding the SDVOB participation requirements, please refer to Appendix F of the RFP.
Note: Information about set asides for SDVOB participation in public procurement can be found which provides guidance for State agencies in making determinations and administering set asides for procurements from SDVOBs.
SDVOB-100 (REV. 9/2017)
|SDVOB UTILIZATION PLAN | Initial Plan | Revised plan |Contract/Solicitation |# |
|INSTRUCTIONS: This Utilization Plan must contain a detailed description of the supplies and/or services to be provided by each NYS Certified Service-Disabled |
|Veteran-Owned Business (SDVOB) under the contract. By submission of this Plan, the Bidder/Contractor commits to making good faith efforts in the utilization of|
|SDVOB subcontractors and suppliers as required by the SDVOB goals contained in the Solicitation/Contract. Making false representations or providing information |
|that shows a lack of good faith as part of, or in conjunction with, the submission of a Utilization Plan is prohibited by law and may result in penalties |
|including, but not limited to, termination of a contract for cause, loss of eligibility to submit future bids, and/or withholding of payments. Firms that do not|
|perform commercially useful functions may not be counted toward SDVOB utilization. Attach additional sheets if necessary. |
|BIDDER/CONTRACTOR INFORMATION |SDVOB Goals In Contract |
|Bidder/Contractor Name: |NYS Vendor ID: | % |
| | | |
|Bidder/Contractor Address (Street, City, State and Zip Code): | |
| | |
|Bidder/Contractor Telephone Number: |Contract Work Location/Region: |
|Contract Description/Title: |
|CONTRACTOR INFORMATION |
|Prepared by (Signature): |Name and Title of Preparer: |Telephone Number: |Date: |
| | | | |
|Email Address: |
|If unable to meet the SDVOB goals set forth in the solicitation/contract, bidder/contractor must submit a request for waiver on the SDVOB Waiver Form. |
|SDVOB Subcontractor/Supplier Name: | |
| | |
|Please identify the person you contacted: |Federal Identification No.: |Telephone No.: |
| | | |
|Address: |Email Address: |
| | |
|Detailed description of work to be provided by subcontractor/supplier: |
| |
|Dollar Value of subcontracts/supplies/services (When $ value cannot be estimated, provide the estimated % of contract work the SDVOB will perform): $ |
|or % |
|SDVOB Subcontractor/Supplier Name: | |
| | |
|Please identify the person you contacted: |Federal Identification No.: |Telephone No.: |
| | | |
|Address: |Email Address: |
| | |
|Detailed Description of work to be provided by subcontractor/supplier: |
| |
|Dollar Value of subcontracts/supplies/services (When $ value cannot be estimated, provide the estimated % of contract work the SDVOB will perform): $ |
|or % |
|FOR OTDA USE ONLY |
|OTDA Authorized Signature: | Accepted | Accepted as Noted | Notice of Deficiency |
|NAME (Please Print): |
|NYS CERTIFIED SDVOB SUBCONTRACTOR/SUPPLIER INFORMATION: The directory of New York State Certified SDVOBs can be viewed at: |
| |
|Note: All listed Subcontractors/Suppliers will be contacted and verified by OTDA |
| |
|ADDITIONAL SHEET |
|Bidder/Contractor Name: |Contract/Solicitation |# |
|SDVOB Subcontractor/Supplier Name: | |
| | |
|Please identify the person you contacted: |Federal Identification No.: |Telephone No.: |
| | | |
|Address: |Email Address: |
| | |
|Detailed Description of work to be provided by subcontractor/supplier: |
| |
|Dollar Value of subcontracts/supplies/services (When $ value cannot be estimated, provide the estimated % of contract work the SDVOB will perform): $ |
|or % |
|SDVOB Subcontractor/Supplier Name: | |
| | |
|Please identify the person you contacted: |Federal Identification No.: |Telephone No.: |
| | | |
|Address: |Email Address: |
| | |
|Detailed Description of work to be provided by subcontractor/supplier: |
| |
|Dollar Value of subcontracts/supplies/services (When $ value cannot be estimated, provide the estimated % of contract work the SDVOB will perform): $ |
|or % |
|SDVOB Subcontractor/Supplier Name: | |
| | |
|Please identify the person you contacted: |Federal Identification No.: |Telephone No.: |
| | | |
|Address: |Email Address: |
| | |
|Detailed Description of work to be provided by subcontractor/supplier: |
| |
|Dollar Value of subcontracts/supplies/services (When $ value cannot be estimated, provide the estimated % of contract work the SDVOB will perform): $ |
|or % |
|SDVOB Subcontractor/Supplier Name: | |
| | |
|Please identify the person you contacted: |Federal Identification No.: |Telephone No.: |
| | | |
|Address: |Email Address: |
| | |
|Detailed Description of work to be provided by subcontractor/supplier: |
| |
|Dollar Value of subcontracts/supplies/services (When $ value cannot be estimated, provide the estimated % of contract work the SDVOB will perform)): $ |
|or % |
|SDVOB Subcontractor/Supplier Name: | |
| | |
|Please identify the person you contacted: |Federal Identification No.: |Telephone No.: |
| | | |
|Address: |Email Address: |
| | |
|Detailed Description of work to be provided by subcontractor/supplier: |
| |
|Dollar Value of subcontracts/supplies/services (When $ value cannot be estimated, provide the estimated % of contract work the SDVOB will perform): $ |
|or % |
|SDVOB-200 (REV. 9/2017) |
|application for Waiver of SDVOB participation goal |
|(must be submitted before requesting final payment on the Contract) |
|Section 1: Basic Information |
|Contractor’s Name: |Federal Identification Number: |
| | |
|Street Address: |E-Mail Address: |
| | |
|City, State, Zip Code: |Telephone: |
| |( ) - |
|Contract Number: |SDVOB CONTRACT GOALS |
| | |
| | % |
|Section 2: Type of SDVOB Waiver Requested |
| Total | Partial |If partial waiver, please enter the revised SDVOB | % |
| | |percentage: | |
|Please explain the reason for the waiver request: |
| |
|Section 3: Supporting Documentation |
| |
|Provide the following documentation as evidence of your good faith efforts to meet the SDVOB goals set forth in the contract and in support of your waiver |
|application: |
|Attachment A. Copies of solicitations to SDVOBs and any responses thereto. |
| |
|Attachment B. Explanation of the specific reasons each SDVOB that responded to Bidders/Contractors’ solicitation was not selected. |
| |
|Attachment C. Dates of any pre-bid, pre-award or other meetings attended by Contractor, if any, scheduled by OTDA with certified SDVOBs whom OTDA determined |
|were capable of fulfilling the SDVOB goals set forth in the contract. |
| |
|Attachment D. Information describing the specific steps undertaken to reasonably structure the contract scope of work for the purpose of subcontracting with, |
|or obtaining supplies from, certified SDVOBs. |
| |
|Attachment E. Other information deemed relevant to the request. |
|Section 4: Signature and Contact Information |
|By signing and submitting this form, the contractor certifies that a good faith effort has been made to promote SDVOB participation pursuant to the SDVOB |
|requirements set forth under the solicitation or Contract. Failure to submit complete and accurate information may result in a finding of noncompliance, |
|non-responsibility, and a suspension or termination of the contract. |
| |
| |
| |
| |
| |
| |
| |
| |
| |
|Prepared By: (Signature) |Date: |
| | |
|Name and Title of Preparer (Print or Type) |
| |
SDVOB-200 (REV. 9/2017)
|For OTDA Use Only |
|Reviewed By: |Date: |
| | |
|Decision: |
| |
|Full SDVOB waiver granted |
|Partial SDVOB waiver granted; revised SDVOB goal: _______ % |
|SDVOB waiver denied |
|Approved By: |Date: |
| | |
|Date Notice of Determination Sent: |
| |
|Comments |
| |
EXHIBIT D-3:
Required Certifications
Contractor/ Subcontractor Background Questionnaire. For the purposes of this document, the applicant is the CONTRACTOR and must complete and sign this form. In addition, the questionnaire must be completed by any proposed co-applicant or supporting organization.
Nondiscrimination in Employment in Northern Ireland
Non-Collusive Bidding Certification
Agreement
Vendor Assurance of No Conflict of Interest or Detrimental Effect (See Appendix M of the RFP)
Contractor/Subcontractor Background Questionnaire
General Information
Federal Identification Number:
Name of Firm:
Mailing Address:
Actual Location:
City: State: Zip code:
Fax Number: ( ) Telephone Number: ( )
|Background Questionnaire |
|The following section must be fully completed by the Bidder or bid will be deemed non-responsive. Where appropriate, provide additional details using space |
|provided or by inserting additional sheets following this part. Any proposed subcontractor must also complete this form if the value of that subcontract will |
|be in excess of $10,000. |
| | |
|1a. If you, the bidder, are a natural person, are you a New York State resident? | NO YES |
| | |
|1b. If you are a corporation, are you a New York State corporation? | NO YES |
| | |
|1c. Are you registered with the New York State Department of State (DOS) to do business in New York State? | |
| | NO YES |
|If no, you will be required to comply with the New York State Department of State guidelines for doing | |
|business in New York State before you will be eligible for a Contract award. Do you agree to these | |
|conditions? | NO YES |
| | |
|2. How many years has the bidder been in business? | Years |
| | |
|3a. Are you a certified minority owned business enterprise, certified by the NYS Department of Economic | |
|Development? (Your company is eligible to be certified if it is at least 51% owned and controlled by | |
|minority group members (i.e. Black, Hispanic, Asian, Pacific Islander, American Indian or Alaskan Native)? | NO YES |
| | |
|3b. Are you a woman owned business enterprise, certified by the NYS Department of Economic Development? | |
|(Your company is eligible to be certified if it is at least 51% owned and controlled by women) | |
| | |
| | NO YES |
| | |
|4. How many people are employed by the bidder? | Employees |
| | |
|Total number of people employed by the bidder: | |
|Within New York State? | |
|Outside of New York State? | |
|Outside of United States? | |
| | |
|6. Is the bidder independently owned and operated? | NO YES |
| |(If no, provide details) |
|7. List and describe any liquidated damages assessed, and/or liens or claims over $25,000 filed against the| |
|bidder and remaining undischarged or unsatisfied for more than 90 days, on any contracts within the past | NO YES |
|five years. | |
|8. Within the past five years has the bidder, any affiliate, any predecessor company or entity, any owner |Check any that apply. If “yes”, describe using |
|of 5.0% or more of the bidder’s equity, or any director, officer, partner, or employee, or other agent of |additional pages if necessary) |
|the bidder who either routinely or frequently acts for the bidder, or has acted for the bidder at any time | |
|in conjunction with the pending contract, or any similar contract with New York State, been the subject of: | |
| | |
|A judgment of conviction for any business-related conducts constituting a crime under state or federal law? | |
| | NO YES |
|A currently pending indictment for any business-related conducts constituting a crime under state or federal| |
|law? | |
| | NO YES |
|A grant of immunity for any business-related conducts constituting a crime under a state or federal law? | |
| | |
|A federal suspension or debarment, New York rejection of any bid or disapproval of any proposed subcontract | NO YES |
|for lack of responsibility, denial or revocation of pre-qualification in any state, or a voluntary exclusion| |
|agreement? | |
| | NO YES |
|A civil or criminal investigation of the New York State Ethics Commission involving a violation(s) of | |
|Section 73 and/or Section 74 of the Public Officer’s Law? | |
| | |
|Any bankruptcy proceeding? | NO YES |
| | |
|Any suspension or revocation of any business or professional license? | |
| | NO YES |
|Anyone whose license to provide health care services under investigation, citation, suspension (including | |
|suspension stayed on compliance with compulsory terms) and/or conviction by any State licensing authority | NO YES |
|for reasons bearing on professional competence, professional conduct, or financial integrity? | |
| | |
|Any failure to notify the OTDA of any investigation, citation, suspension (including suspension stayed on | NO YES |
|compliance with compulsory terms) and/or conviction by a State agency of a matter within its jurisdiction? | |
| | |
|Any citations, Notices, violation orders, pending administrative hearings or proceedings or determinations | |
|for violations of: | NO YES |
| | |
|federal, state or local health laws, rules or regulations; | |
|unemployment insurance or worker’s compensation coverage or claim requirements; | |
|ERISA (Employee Retirement Income Security ACT); | NO YES |
|federal, state or local human rights laws; or, | |
|federal, state security laws? | |
| | NO YES |
| | NO YES |
|A grant of immunity for any business-related conducts constituting a crime under a state or federal law? | NO YES |
| | NO YES |
| | NO YES |
|Any federal determination of a violation of any labor law or regulation, or any OSHA serious violation? | |
| | |
|Was violation willful? | NO YES |
| | |
| | |
|Any state determination of a violation of any labor law or regulation? | |
| | NO YES |
| | |
|Any state determination of a Public work violation? | |
| | NO YES |
|Was violation deemed willful? | |
| | |
| | NO YES |
|A revocation of MBE or WBE certification? | |
| | |
| | NO YES |
|A rejection of a low bid on a state contract for failure to meet statutory affirmative action or MWBE | |
|requirements? | NO YES |
| | |
| | |
|A consent order with the NYS Department of Environmental Conservation, or a federal or state enforcement | NO YES |
|determination involving a construction-related violation of federal or state environmental laws? | |
| | |
| | NO YES |
| | |
| | |
| | |
| | |
| | NO YES |
| | |
|9. Does your company retain partnership or reciprocal agreements with hardware and/or software companies, or| NO YES |
|with associated manufacturers in this industry? | |
| | |
|10. Does the bidder hold any current contracts with the State of New York, its departments or political | NO YES |
|subdivisions, valued in excess of $100,000? |(If yes, provide details) |
| | |
|11. Does the bidder hold any current contracts with governmental entities outside of New York State, valued | NO YES |
|in excess of $100,000: |(If yes, provide details) |
| | |
|12. Your firm is responsible for providing worker’s compensation insurance pursuant to state law. The State| |
|has the option to require proof of current worker’s compensation insurance or proof of exemption if | NO YES |
|applicable. Do you comply with this requirement? | |
| | |
|13. Your firm is responsible for providing disability insurance pursuant to state law. The State has the | |
|option to require proof of current worker’s compensation insurance or proof of exemption if applicable. Do | |
|you comply with this requirement? | NO YES |
| | |
|14. Does your firm employ any non-U.S. citizens or resident legal aliens? | NO YES |
| | |
| | |
|If yes, are the forms on file and available for inspection? | NO YES |
CERTIFICATION
The undersigned: 1) recognizes that this questionnaire is submitted for the express purpose of inducing the New York State Office of Temporary of Disability Assistance to award a contract or approve a subcontract; 2) acknowledges that the Office may in its discretion, by means which it may choose, determine the truth and accuracy of all statements made herein; 3) acknowledges that intentional submission of false or misleading information may constitute a felony under Penal Law 210.40 or a misdemeanor under Penal Law 210.35 or 210.45, and may also be punishable by a fine of up to $10,000 or imprisonment of up to five years under 18 U.S.C. 1001; 4) states that the information submitted in this questionnaire and any attached pages is true, accurate and complete; and, 5) acknowledges that submission of false or misleading information will constitute grounds for the Office to terminate its contract (or revoke its approval of a subcontract) with the undersigned or the organization of which s/he is an officer.
Authorized Signature:
Name:
Title:
Date:
Nondiscrimination in Employment in
Northern Ireland:
MacBride Fair Employment Principles
In accordance with section 165 of the State Finance Law, the bidder, by submission of this bid certifies that it or any individual or legal entity in which the bidder holds a 10% or greater ownership interest, or any individual or legal entity that holds a 10% or greater ownership in the bidder, either: (answer yes or no to one or both of the following, as applicable):
1. Has business operations in Northern Ireland
Yes No
if yes,
2. Shall take lawful steps in good faith to conduct any business operations that it has in Northern Ireland in accordance with the MacBride Fair Employment Principles relating to nondiscrimination in employment and freedom of workplace opportunity regarding such operations in Northern Ireland, and shall permit independent monitoring of their compliance with such Principles.
Yes No
__________________________________________________
Signature
Non-Collusive Bidding Certification Required
by Section 139-D of the State Finance Law
SECTION 139-D. Statement of Non-Collusion in Bids to the State:
BY SUBMISSION OF THIS BID, BIDDER AND EACH PERSON SIGNING ON BEHALF OF BIDDER CERTIFIES, AND IN THE CASE OF A JOINT BID, EACH PARTY THERETO CERTIFIES AS TO ITS OWN ORGANIZATION, UNDER PENALTY OR PERJURY, THAT TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF:
[1] The prices of this bid have been arrived at independently, without collusion, consultation, communication, or agreement, for the purposes of restricting competition, as to any matter relating to such prices with any other Bidder or with any competitor;
[2] Unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the Bidder and will not knowingly be disclosed by the bidder prior to opening, directly or indirectly, to any other bidder or to any competitor; and
[3] No attempt has been made or will be made by the Bidder to induce any other person, partnership or corporation to submit or not to submit a bid for the purpose of restricting competition.
A BID SHALL NOT BE CONSIDERED FOR AWARD NOR SHALL ANY AWARD BE MADE WHERE [1], [2] AND [3] ABOVE HAVE NOT BEEN COMPLIED WITH; PROVIDED HOWEVER, THAT IF IN ANY CASE THE BIDDER(S) CANNOT MAKE THE FOREGOING CERTIFICATION, THE BIDDER SHALL SO STATE AND SHALL FURNISH BELOW A SIGNED STATEMENT WHICH SETS FORTH IN DETAIL THE REASONS THEREFORE:
[AFFIX ADDENDUM TO THIS PAGE IF SPACE IS REQUIRED FOR STATEMENT]
Subscribed to under penalty of perjury under the laws of the State of New York, this _____ day of ________________________, 20___ as the act and deed of said corporation or partnership.
Potential Contractor:
Address:
Street City State Zip
Telephone: Title:
If applicable, responsible Corporate Officer
Name: Title:
Signature: ____________________________________________________________________
JOINT OR COMBINED BIDS MUST BE CERTIFIED ON BEHALF OF EACH PARTICIPANT.
Legal name of person, firm or corporation Legal name of person, firm or corporation
By: By:
Name Name
Title Title
Street Address Street Address
City/State City/State
Agreement
It is understood and agreed to by the applicant and co-applicant, if and, that: (1) Applicant organization meets the requirements of a local recipient organization. It is a municipality, non-profit corporation or charitable organization, has an accounting system, and practices non-discrimination. (2) Funds received from the New York State Homeless Housing and Assistance Program will be expended in accordance with the state guidelines established for such purposes. (3) The organization agrees to comply with the requirements of the Civil Rights Act of 1964 as amended, and all applicable Federal Regulations contained in 44 CFR, Part 7, entitled "Nondiscrimination in Federally-Assisted Programs," and agrees that the expression of religious belief or religious activity shall not be a condition to receiving shelter or services. (4) The funds may be terminated in whole, or in part, by the Commissioner of the New York State Office of Temporary & Disability Assistance. Such termination shall not affect obligations incurred under the contract prior to the effective date of such termination. (5) When funds are advanced, any unexpended balance at the end of the approval period will be returned. (6) Any significant revision of the approved project proposal will be requested in writing by the awardee prior to the enactment of the change. (7) Progress reports will be submitted as required by the HHAC. The final program and financial reports will be submitted as required by the HHAC. Final program and financial reports will be submitted within one month after the project terminates. All necessary records and accounts, including financial and property controls, will be maintained and made available to the New York State Office of Temporary & Disability Assistance for audit purposes. (8) All reports of investigations, studies, publications, etc., made as a result of this proposal will acknowledge the support provided by the New York State Office of Temporary & Disability Assistance and the Homeless Housing and Assistance Corporation. (9) All personal information concerning individuals served or studied under the project is confidential and such information may not be disclosed to unauthorized persons. (10) The New York State Office of Temporary & Disability Assistance and Homeless Housing and Assistance Corporation reserve a royalty-free non-exclusive license to use and authorize others to use all copyrighted material resulting from this project. (11) The applicant shall comply with all program requirements stated in this Request for Proposals, and with all applicable laws and regulations, in establishing and operating its Homeless Project.
The applicant and co-applicant, if any, certifies that to the best of its knowledge and belief the data in this application are true and correct, that it will comply with the above agreement if it receives funding, and that this constitutes a firm offer for 150 days.
APPLICANT AGENCY
______________________________________________________________________________
SIGNATURE OF OFFICIAL AUTHORIZED TO SIGN FOR APPLICANT
Date TITLE
CO-APPLICANT AGENCY
______________________________________________________________________________
SIGNATURE OF OFFICIAL AUTHORIZED TO SIGN FOR CO-APPLICANT
Date TITLE
Vendor Assurance of No Conflict of Interest or Detrimental Effect
The Applicant offering to provide services pursuant to this Homeless Housing and Assistance Corporation (“HHAC”)RFP, as a contractor, joint venture contractor, subcontractor, or consultant, attests that its performance of the services outlined in this RFP does not and will not create a conflict of interest with nor position the Applicant to breach any other contract currently in force with the State of New York.
Furthermore, the Applicant attests that it will not act in any manner that is detrimental to any State or HHAC project on which the Applicant is rendering services. Specifically, the Applicant attests that:
1. The fulfillment of obligations by the Applicant, as proposed in the RFP response, does not violate any existing contracts or agreements between the Applicant and the State or HHAC;
2. The fulfillment of obligations by the Applicant, as proposed in the RFP response, does not and will not create any conflict of interest, or perception thereof, with any current role or responsibility that the Applicant has with regard to any existing contracts or agreements between the Applicant and the State or HHAC;
3. The fulfillment of obligations by the Applicant, as proposed in the RFP response, does not and will not compromise the Applicant’s ability to carry out its obligations under any existing contracts between the Applicant and the State or HHAC;
4. The fulfillment of any other contractual obligations that the Applicant has with the State or HHAC will not affect or influence its ability to perform under any contract with the State or HHAC resulting from this RFP;
5. During the negotiation and execution of any contract resulting from this RFP, the Applicant will not knowingly take any action or make any decision which creates a potential for conflict of interest or might cause a detrimental impact to the State or HHAC as a whole including, but not limited to, any action or decision to divert resources from one State or HHAC project to another;
6. In fulfilling obligations under each of its State contracts, including any contract which results from this RFP, the Applicant will act in accordance with the terms of each of its State or HHAC contracts and will not knowingly take any action or make any decision which might cause a detrimental impact to the State or HHAC as a whole including, but not limited to, any action or decision to divert resources from one State or HHAC project to another;
7. No former officer or employee of the State who is now employed by the Applicant, nor any former officer or employee of the Applicant who is now employed by the State, has played a role with regard to the administration of this contract procurement in a manner that may violate section 73(8)(a) of the State Ethics Law; and
8. The Applicant has not and shall not offer to any employee, member or director of the State any gift, whether in the form of money, service, loan, travel, entertainment, hospitality, thing or promise, or in any other form, under circumstances in which it could reasonably be inferred that the gift was intended to influence said employee, member or director, or could reasonably be expected to influence said employee, member or director, in the performance of the official duty of said employee, member or director or was intended as a reward for any official action on the part of said employee, member or director.
Applicants responding to this RFP should note that the State and HHAC recognizes that conflicts may occur in the future because an Applicant may have existing or new relationships. HHAC will review the nature of any such new relationship and reserves the right to terminate the contract for cause if, in its judgment, a real or potential conflict of interest cannot be cured.
Name, Title:
Signature: Date:
This form must be signed by an authorized executive or legal representative.
EXHIBIT E-1: Site Description
(Duplicate this page for each building in the proposed project)
Site of
Site Address:
A) Describe the design and current condition of the project premises.
B) Detail the proximity of this site to public transportation, community and municipal services, day care, shopping and medical services, etc.
C) Describe any plans to relocate current residents (if any) from this site during the needed repairs.
Add additional sheets if needed and label Project Site Information
EXHIBIT E-2:
Scope of Work and Cost Estimate (Page 1 of 2)
(If more than one site, duplicate this section for each building in the proposed project.)
Site of
Site Address:
Level of Construction Work Required
Moderate Rehabilitation
Purchasing Equipment
Project will be Constructed by:
General Contractor Selected via Bid; or
Preselected* General Contractor (GC); or
Construction Manager^ Selected via Bid; or
Preselected Construction Manager*^(CM) with Subcontractors Selected via Bid; or
Other, please specify: Provide three quotes when just requesting funding for small/ standalone repairs (e.g., roof replacement) or the purchase of equipment (i.e., security systems, fire alarm systems).
If proposing a preselected construction manager or contractor, identify the individual or firm below and provide contact and other information as required in Exhibit A-6. In addition, please provide justification for utilizing the services of a preselected GC or CM and indicate whether the firm is a W/MBE or a SDVOB.
WBE MBE NYS Certified? Yes No
SDVOB NYS Certified? Yes No
*Note: HHAC requires that a minimum of 50% of the value of the work is competitively bid, which may be accomplished through trade subcontractors. In lieu of bidding 50% of the total construction value HHAC may, at its discretion, accept a bid plan and matrix for review and approval. If there is an identity of interest among a sponsor/owner development team and the pre-selected general contractor or construction manager, HHAC may, in its sole discretion, require that all trades or subcontracts be competitively bid.
**Note: HHAC will not entertain utilizing the services of a Construction Manager as Advisor (CMA); HHAC will only consider utilizing the services of a Construction Manager as Constructor (CMC).
EXHIBIT E-2: Scope of Work and Cost Estimate
(Page 2 of 2)
Site of
Site Address:
Scope of Work
1) Based on the current condition of the building as described in Exhibit E-1, provide a narrative scope of work describing, in detail, work to be performed. The scope of work for rehabilitation projects should be comprehensive and should address each significant building component and state whether it is to be repaired and/ or replaced and to what extent.
2) In addition, provide a detailed estimate of the cost of work or three quotes for equipment to be purchased. Please note that while HHAP funding does not trigger prevailing wage requirements, some funding sources may. Indicate below whether the attached cost estimate is based on prevailing wages.
3) Please provide an explanation of how life-cycle costs were considered in developing the scope of work in terms of durability of materials and equipment, cost and ease of maintenance and operations.
The construction cost estimate is is not based on prevailing wages.
An incomplete response to this section may result in the disqualification of the proposal.
EXHIBIT E-3: Zoning Analysis and Status of Local Approvals
(If more than one site, duplicate this page for each building in the proposed project.)
Site of
Site Address:
Zoning Analysis
Current Zoning (attach map)
Permitted Uses (attach applicable excerpt of regulations)
This Use
What is permitted floor area? (Most conservative estimate)
Does the proposed design and density conform to local zoning? If not, describe the situation and explain why the project cannot be re-designed to be “as of right”.
If a zoning change, variance, special use permit or other related approval is required for the project to operate, explain the action and the time required to accomplish such a change or gain approval. Attach evidence that the local planning or building authority has been notified of the intent to seek the change or approval, that the action has been applied for, and, if already approved, evidence of such approval.
Status of Local Approvals
List below the local approvals necessary to develop the proposed project and describe the current status of such approvals and whether any requests for approval have been denied. Following this page, attach documentation of all approvals that have been granted or denied.
EXHIBIT 4:
Project Timeline
Please estimate the total timeframe (in months) for development of the proposed repairs from notification of award to project completion and provide the estimated month and year for achieving major project milestones in the chart below. Please add additional milestones as appropriate.
Total Timeframe for Development:
| | | |Estimated Date of |
| | |Contact Person |Completion |
|Milestone |Status |and Phone Number |(Month/ Year) |
|Development Funding Commitments | | | |
|(other than HHAP) | | | |
|Operating Funding Commitments | | | |
|Code Variance, if applicable | | | |
|Area Variance, if applicable | | | |
|Change in Use Permit, if applicable | | | |
|Easement, if applicable | | | |
|Use Variance, if applicable | | | |
|Other (specify) | | | |
|Site Plan Approval, if applicable | | | |
|Zoning Approval, if applicable | | | |
|SHPO Determination, if applicable | | | |
|Design Phase, if applicable | | | |
|Bid and Award, if applicable | | | |
|Building Permit Secured, if applicable | | | |
|Repair Work/ Installation of Equipment Start | | | |
|Repairs/ Installation Complete | | | |
|Certificate of Occupancy (if applicable) | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
EXHIBIT E-5:
State Historic Preservation Office (SHPO) Submission and
State Environmental Quality Review (SEQR) (Page 1 of 2)
1. All applicants must complete the SHPO’s online CRIS process on the State Office of Parks, Recreation and Historic Preservation’s website for eligibility review prior to submitting the application. Please submit all projects directly into CRIS. You will find a link to the system and a link to a tutorial on their website at -- shpo/online-tools/.
While you can submit projects as a guest, registering will save time in the future if you are going to be working with the system on a long-term basis. See information at the end regarding registration. Several tips:
• Begin by using the “Submit” tab on the landing page and choosing “Consultation Project.”
• Please include contact information for anyone who should receive communication about findings, and that includes staff at any permitting or funding agency (*Please specify that an application is being submitted to HHAP). For SEQRA submissions, it is important to include a contact for the municipality, such as the chair of the planning board and/or planning staff.
• For projects submitted as a SEQRA Lead Agency notice, please clarify whether there will be additional permits or sources of funding involved in future phases of the project. If it is likely that the development will require a state or federal permit in a later phase (such as a DEC or Army Corps permit) we may review the project under Section 14.09 or 106. Provide contact information for the agency or agencies involved.
• Always provide a description of the project. When uploading materials, be sure to wait until Step 5 to submit your project documents such as a scope of work and maps.
• Under the Built Resources section, place the photos for any buildings. Do not place any scopes of work or maps in this section, but wait until Step 5. When uploading photos and materials for buildings, include any outbuildings or related structures under the same resource. Do not create a separate built resource entry for garages, sheds, walls. etc.
• If you have a question regarding a project and would like to check with SHPO staff before submitting materials, you will be able to find contacts for each county at .
SHPO currently recommends that new registered users create personal ID accounts (rather than business or government ID accounts) using their preferred email address for SHPO correspondence, since personal accounts do not require agency approval to activate. Some agencies’ services distinguish the three different account types, but CRIS does not.
The first time you log into CRIS with a ID account, you will automatically be added to the CRIS user database. After you have logged in, you may click the My Profile link in the upper right corner of the CRIS page to edit your contact information (such as organization, address, and phone number). This information will automatically be entered in the primary contact form when you start a new submission.
If you need assistance using CRIS, contact the help desk at CRISHelp@parks..
Please include in your application proof of the electronic submission to CRIS.
EXHIBIT E-5:
State Historic Preservation Office (SHPO) Submission And
State Environmental Quality Review (SEQR)
(Page 2 of 2)
If the project site is a historic building or in a historic district, what impact will this have on project cost and design? Has either local landmarks or State Historic Preservation been consulted on this project? If so, describe any comments/concerns identified and how they will be addressed.
2. Submission of the short Environmental Assessment Form (EAF provided) with the application is required for compliance with the State Environmental Quality Review Act (SEQRA) procedures. The applicant is responsible for completing only Part 1 of the three-part form. The Lead Agency will complete Parts 2 and 3, as necessary.
*Please note – If Shelter Application is solely to purchase security cameras/ systems, SHPO/SEQRA does not apply.
Short Environmental Assessment Form
Instructions for Completing
Part 1 - Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding, are subject to public review, and may be subject to further verification. Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully respond to any item, please answer as thoroughly as possible based on current information.
Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency; attach additional pages as necessary to supplement any item.
|Part 1 - Project and Sponsor Information |
|Name of Action or Project: |
|Project Location (describe, and attach a location map): |
|Brief Description of Proposed Action: |
|Name of Applicant or Sponsor: |Telephone: |
| |E-Mail: |
|Address: |
|City/PO: |State: |Zip Code: |
|1. Does the proposed action only involve the legislative adoption of a plan, local law, ordinance, administrative rule, or |NO |YES |
|regulation? | | |
|If Yes, attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in | | |
|the municipality and proceed to Part 2. If no, continue to question 2. | | |
| | | |
|2. Does the proposed action require a permit, approval or funding from any other governmental Agency? If Yes, list agency(s) name |NO |YES |
|and permit or approval: | | |
| | | |
|3.a. Total acreage of the site of the proposed action? acres |
|Total acreage to be physically disturbed? acres |
|Total acreage (project site and any contiguous properties) owned |
|or controlled by the applicant or project sponsor? acres |
|4. Check all land uses that occur on, adjoining and near the proposed action. |
|ο Urban ο Rural (non-agriculture) οIndustrial ο Commercial ο Residential (suburban) |
|ο Forest ο Agriculture ο Aquatic ο Other (specify): |
|οParkland |
|Is the proposed action, |NO |YES |N/A |
|A permitted use under the zoning regulations? | | | |
| | | | |
|Consistent with the adopted comprehensive plan? | | | |
| | | | |
| | | | |
|6. Is the proposed action consistent with the predominant character of the existing built or natural landscape? |NO |YES |
| | | |
|7. Is the site of the proposed action located in, or does it adjoin, a state listed Critical Environmental Area? If Yes, identify: |NO |YES |
| | | |
|a. Will the proposed action result in a substantial increase in traffic above present levels? |NO |YES |
| | | |
| | | |
|Are public transportation service(s) available at or near the site of the proposed action? | | |
| | | |
|Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? | | |
| | | |
| | | |
| | | |
|9. Does the proposed action meet or exceed the state energy code requirements? |NO |YES |
|If the proposed action will exceed requirements, describe design features and technologies: | | |
| | | |
|10. Will the proposed action connect to an existing public/private water supply? |NO |YES |
|[If Yes, does the existing system have capacity to provide service? ο NO ο YES] | | |
|If No, describe method for providing potable water: | | |
| | | |
|11. Will the proposed action connect to existing wastewater utilities? |NO |YES |
|[If Yes, does the existing system have capacity to provide service? ο NO ο YES] | | |
|If No, describe method for providing wastewater treatment: | | |
| | | |
|12. a. Does the site contain a structure that is listed on either the State or National Register of Historic Places? |NO |YES |
|b. Is the proposed action located in an archeological sensitive area? | | |
| | | |
| | | |
|13. a. Does any portion of the site of the proposed action, or lands adjoining the proposed action, contain wetlands or other |NO |YES |
|waterbodies regulated by a federal, state or local agency? | | |
|b. Would the proposed action physically alter, or encroach into, any existing wetland or waterbody? | | |
|If Yes, identify the wetland or waterbody and extent of alterations in square feet or acres: | | |
| | | |
| | | |
| | | |
|Identify the typical habitat types that occur on, or are likely to be found on the project site. Check all that apply: |
|Shoreline ο Forest ο Agricultural/grasslands ο Early mid-successional |
|Wetland ο Urban ο Suburban |
|15. Does the site of the proposed action contain any species of animal, or associated habitats, listed by the State or Federal |NO |YES |
|government as threatened or endangered? | | |
| | | |
|16. Is the project site located in the 100 year flood plain? |NO |YES |
| | | |
|Will the proposed action create storm water discharge, either from point or non-point sources? If Yes, |NO |YES |
|Will storm water discharges flow to adjacent properties? ο NO ο YES | | |
| | | |
|Will storm water discharges be directed to established conveyance systems (runoff and storm drains)? If Yes, briefly describe: ο NO ο| | |
|YES | | |
| | | |
| | | |
| | | |
|18. Does the proposed action include construction or other activities that result in the impoundment of water or other liquids (e.g. |NO |YES |
|retention pond, waste lagoon, dam)? | | |
|If Yes, explain purpose and size: | | |
| | | |
|19. Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste management |NO |YES |
|facility? | | |
|If Yes, describe: | | |
| | | |
|20. Has the site of the proposed action or an adjoining property been the subject of remediation (ongoing or completed) for hazardous|NO |YES |
|waste? | | |
|If Yes, describe: | | |
| | | |
|I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE |
|Applicant/sponsor name: Date: Signature: |
Part 2 - Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept “Have my responses been reasonable considering the scale and context of the proposed action?”
| |No, or small|Existing |
| |impact may |Moderate to |
| |occur |large impact |
| | |may occur |
|1. |Will the proposed action create a material conflict with an adopted land use plan or zoning regulations? | | |
|2. |Will the proposed action result in a change in the use or intensity of use of land? | | |
|3. |Will the proposed action impair the character or quality of the existing community? | | |
|4. |Will the proposed action have an impact on the environmental characteristics that caused the establishment of a | | |
| |Critical Environmental Area (CEA)? | | |
|5. |Will the proposed action result in an adverse change in the existing level of traffic or affect existing | | |
| |infrastructure for mass transit, biking or walkway? | | |
|6. |Will the proposed action cause an increase in the use of energy and it fails to incorporate reasonably available | | |
| |energy conservation or renewable energy opportunities? | | |
|7. |Will the proposed action impact existing: | | |
| |public / private water supplies? | | |
| |public / private wastewater treatment utilities? | | |
| | | | |
|8. |Will the proposed action impair the character or quality of important historic, archaeological, architectural or | | |
| |aesthetic resources? | | |
|9. |Will the proposed action result in an adverse change to natural resources (e.g., wetlands, waterbodies, groundwater, | | |
| |air quality, flora and fauna)? | | |
| |No, or small|Moderate to |
| |impact may |large impact |
| |occur |may occur |
|10. Will the proposed action result in an increase in the potential for erosion, flooding or drainage problems? | | |
|11. Will the proposed action create a hazard to environmental resources or human health? | | |
Part 3 - Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered “moderate to large impact may occur”, or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact, please complete Part 3. Part 3 should, in sufficient detail, identify the impact, including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant. Each potential impact should be assessed considering its setting, probability of occurring, duration, irreversibility, geographic scope and magnitude. Also consider the potential for short-term, long-term and cumulative impacts.
ο Check this box if you have determined, based on the information and analysis above, and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required.
ο Check this box if you have determined, based on the information and analysis above, and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts.
Name of Lead Agency Date
Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer
Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from Responsible Officer)
EXHIBIT E-6:
Flood Plain Letter
Following this page, attach a flood plain letter from the jurisdictional authority or equivalent official determination indicating whether the project site(s) are in a Special Flood Hazard Area (SFHA). Be sure to verify that the information presented is based on the most current map/ official flood zone determinations.
EXHIBIT E-7:
Site Photographs
1) Following this page, attach six (6) color photographs of the site(s), one facing the front of the site, one facing the rear of the site, and views from the site looking east, west, north and south. If more than one site is proposed, provide photographs of each project site and make sure that the photos are clearly labeled.
2) Please include photo documentation of the site conditions that, if not corrected, may impact the health and safety of tenants and/or the ongoing viability of the project.
EXHIBIT E-8:
Floor Plans
Following this page, for each project site, provide:
Location plan showing the location of the project in the context of surrounding buildings/ neighborhood (1” = 100’ scale).
“As is” existing floor plans
Sketch Plans of the proposed building: site plan (minimum scale 1” = 40’), each floor plan (minimum scale 1/8” = 1.0”), typical unit. (¼” = 1’ scale)
One full set of architectural plans and copies of plans reduced to letter size (8 ½ x 11) should be provided, if applicable, with each hard copy of the application submitted. Plans included in the electronic copy of the submission should be provided in .pdf format and printable to a maximum of ledger sized paper.
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M/WBE
EEO
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